Provider Demographics
NPI:1558401968
Name:PEDDYCOART, BRENWYN ANNE LISA (DC)
Entity Type:Individual
Prefix:
First Name:BRENWYN
Middle Name:ANNE LISA
Last Name:PEDDYCOART
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 BUERKLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5269
Mailing Address - Country:US
Mailing Address - Phone:651-770-8424
Mailing Address - Fax:651-770-3170
Practice Address - Street 1:1803 BUERKLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-5269
Practice Address - Country:US
Practice Address - Phone:651-770-8424
Practice Address - Fax:651-770-3170
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11F47PEOtherBCBS
U60253Medicare UPIN
11F47PEOtherBCBS